Where a spiritual descendant of Sir William Osler and Abbie Hoffman holds forth on issues of medicine, media and politics. Mostly.

Tuesday, September 28, 2010

The HIV Epidemic Rolls On

"Shocking" is a word I prefer not to use much--to me, it smacks simultaneously of Leave-It-To-Beaver-era naivete and reality-TV-let's-outdo-ourselves-era behavior--but I'm hard pressed to come up with a better word to describe this week's report from the CDC about the prevalence and awareness of HIV infection among Men who have Sex with Men. Most laypeople would describe these people as "homosexual" or "gay," but the clinical term has trended toward using the acronym "MSM." This is because some men, whether for reasons owing to homophobia in their communities or to a bisexual lifestyle or both, may not define themselves as "gay" but still fit into that epidemiologic group. It's not a trivial distinction, as the act of having unprotected sex with a man who has sex with other men is, no matter what he calls himself, statistically, a much more risky proposition than having sex with one who doesn't.

Thirty years into the HIV epidemic, that shouldn't be. There should be no group more painfully aware of the ravages of this virus than gay men. An entire generation was, if not destroyed, at least pummeled by HIV. And as Randy Shilts's excellent book And The Band Played On laments, it wasn't just the kind of dark paranoia of Ronald Reagan's administration that fanned the flames of the epidemic in New York and San Fransisco in the early 1980's: the patrons and owners of gay bars and sex clubs were equally interested in ignoring early compelling evidence that something wicked was coming. Tens of thousands of people--again, mostly gay men--died as a consequence.

So if any group should be hypersensitive to the need for basic Sex Ed and the usefulness of protective sex, or at least the value in frequent HIV testing in the absence of safe sex, it should be gay men. Alas, the CDC reports this week that such is not the case. The numbers can be a bit overwhelming when you examine all of them in detail, but the bottom line is actually quite simple: nearly half of all men actively having sex with other men that are HIV-positive are totally unaware that they are infected. (Of the roughly 8,000 men who were tested, 19% were infected, which means that approximately 10 percent of men who have sex with men are both HIV-positive and unaware of this. Russian roulette, anyone?)

These stats probably represent a slight overestimate of the true number of gay men who are infected and unaware, since the men were recruited to the study were found at "appropriate venues," such as bars, organizations, and street locations where gay men were known to congregate. Thus, this group is probably more sexually active and potentially more promiscuous than the larger community. That said, it's still cold comfort: the seroprevalence in this community, despite all that has happened to them and all the suffering they have gone through over the past three decades, is basically that of sub-Saharan Africa.

If you sift through the numbers, you will see that it's even worse for MSMs in minority communities, especially blacks, where the HIV prevalence was just under one in three (the prevalence for Latinos, at 18 percent, was only slightly higher than that for whites, at 16 percent).

I would like to think that I'm not shocked by much, but this leaves my jaw in a state of drop.

You might wonder why, in an age of effective medical therapy for HIV, I'm making such a big deal out of this study. After all, once they find out they're infected, can't they just take medications and everything will be okay?

Well, no. There's two major problems with this analysis. First is that there is abundant evidence that people whose HIV infection is treated earlier tend to live longer and suffer fewer complications from the disease (such as cancer, among many other things). Second, and even more importantly from a public health standpoint, is that people who are HIV-positive but on treatment are far less likely to spread the virus. When half of one of the largest groups of people infected with the virus are unaware of their infection, controlling it is a pipe dream. And because this group still does have sex with others outside its "own group," everyone remains at risk.

--br

PS--Apropos of nothing much, I continue to be annoyed, like many, at the infantile way in which the modern media seems to have constructed political debate, where apparently only two positions seem tenable: that of laissez-faire capitalism or Stalinist/Maoist/Marxist (choose your favorite!) communism. Today, Paul Krugman of The New York Times has one of the more eloquent rejoinders to this kind of diatribing,

The market economy is a system for organizing activity — a pretty good system most of the time, though not always — with no special moral significance. The rich don’t necessarily deserve their wealth, and the poor certainly don’t deserve their poverty; nonetheless, we accept a system with considerable inequality because systems without any inequality don’t work. And before the trolls jump in to say aha, Krugman concedes the truth of supply-side economics, that’s not an argument against progressive taxation and the welfare state; it’s just an argument that says that there are limits. Cuba doesn’t work; Sweden works pretty well.

2 comments:

Why? F-to-M transmission is so rare that it's quite clear that M-to-M will invariably be riskier, even if MSMs practiced safer sex than heterosexuals.

Now, fact is that they don't, but that's a different issue. And here's a falsifiable prediction: unsafe MSM sex will go up if we ever get universal health care and taxpayers are on the hook for HIV treatment.

Apologies for the misleading statement. When I wrote that “thirty years into the HIV epidemic, that shouldn’t be,” that was meant to refer to a profound lack of vigilance among gay men for the risks of unsafe sex. Given that the gay community is more intimately acquainted with the consequences of these practices than any other group in the US, the fact that nearly one in ten gay men are both infected and unaware of it is pretty appalling. I didn’t mean to imply that there should have been some change in the pathophysiology of how the virus is transmitted. You are correct; F to M transmission via sex is, particularly in the US, much less likely to occur than between men (or from a man to a woman, since semen is loaded with virus).

That said, HIV is largely a disease of heterosexuals around the world. Current estimates are that about 40 million people are infected with the virus, and the overwhelming number of these people engage in what most people would regard as “conventional” heterosexual behavior. The epidemic in the US and, to a lesser extent, in Europe has always been peculiar in their disproportionate number of gay men who are infected.

Subscribe To

About Me

I'm a physician and an educator with a clinical focus in infectious disease. I teach the spectrum from 3rd year medical students through senior ID fellows, and try to keep everyone loose when doing so. Whether I succeed or not, you'll have to ask them.
I am interested in issues where medicine intersects with politics, as well as how medical research is portrayed by media. In some ways my views are very much at the fringe of the rest of the physician community, although in several other critical ways I’m your typical stethoscope-wielding, white-coat-wearing, reflex-hammer-tapping doc and consider myself steeped in the traditions of the brotherhood and sisterhood.